Mechanical strain induces involution-associated events in mammary epithelial cells

Background  

Shortly after weaning, a complex multi-step process that leads to massive epithelial apoptosis is triggered by tissue local factors in the mouse mammary gland. Several reports have demonstrated the relevance of mechanical stress to induce adaptive responses in different cell types. Interestingly, these signaling pathways also participate in mammary gland involution. Then, it has been suggested that cell stretching caused by milk accumulation after weaning might be the first stimulus that initiates the complete remodeling of the mammary gland. However, no previous report has demonstrated the impact of mechanical stress on mammary cell physiology. To address this issue, we have designed a new practical device that allowed us to evaluate the effects of radial stretching on mammary epithelial cells in culture.     

Characterisation of physiological and immunological responses in beef cows to abrupt weaning and subsequent housing

Background  

Weaning involves the permanent separation of the calf from the dam and has been shown to be stressful for both. The objectives of this study were to characterise the effect of i) abrupt weaning and ii) subsequent housing on the extended physiological and immunological responses of beef cows. At weaning (day (d) 0, mean age of calf (s.d.) 212 (24.5) d), cows were abruptly separated from their calves and returned to the grazing area. After 35 d at pasture, cows were housed in a slatted floor shed and offered grass silage ad libitum plus a mineral-vitamin supplement daily. Rectal body temperature was recorded and blood samples were obtained on i) d 0 (weaning), 2, 7, 14, 21, 28, 35 and subsequently on ii) d 0 (housing), 2, 7, 14 and 21 for physiological, haematological and immunological measurements.     

Effect of a disinfection strategy on the methicillin‐resistant Staphylococcus aureus CC398 prevalence of sows,their piglets and the barn environment

Aims

To assess, in a cleaned and disinfected barn environment, the efficacy of an animal disinfection strategy to reduce the livestock‐associated methicillin‐resistant Staphylococcus aureus (LA‐MRSA) prevalence in sows, their offspring and the barn environment.

Methods and Results

On each farm, six sow rounds were sampled; sows were divided into either a test or control group. Per round, 20 sows and 40 of their piglets were sampled at different time points together with the barn environment. The disinfection strategy of the test groups consisted of washing the sows with a shampoo followed by disinfection of the skin with a solution containing chlorhexidine digluconate and isopropanol. On the first day of disinfection and 6 days after stopping the disinfection, a significant decrease (P < 0·01) of on average 68 and 66% in sow MRSA prevalence was observed on both farms, whereas no decrease was seen in the control groups. Just before weaning, 21–28 days after the end of the disinfection strategy, the difference in MRSA prevalence between both groups was reduced to 4% and no longer significant (P = 0·20). The MRSA prevalence of the piglets in the test groups was significantly lower (26%; P < 0·01) 6 days after the end of disinfection. Just before weaning, this difference was reduced to 5% but still significant (P < 0·01). In the swine nursery unit, no significant difference (P = 0·99) was seen between both groups. Based on semi‐quantitative counts, a relationship (r² > 0·6; P < 0·01) was seen between MRSA contamination in the barn environment and the MRSA prevalence in pigs.

Conclusion

Results show that the tested disinfection strategy reduces temporarily the sow and piglet MRSA status, but does not result in a final reduction in MRSA at weaning or in the nursery unit.

Significance and Impact of the Study

First report on the efficacy of an animal disinfection strategy to reduce LA‐MRSA prevalence in sows, their offspring and the barn environment.     

Changes in oxygen partial pressure of brain tissue in an animal model of obstructive apnea

Background

Prolonged weaning from mechanical ventilation has a major impact on ICU bed occupancy and patient outcome, and has significant cost implications. There is evidence in patients around the period of extubation that helium-oxygen leads to a reduction in the work of breathing. Therefore breathing helium-oxygen during weaning may be a useful adjunct to facilitate weaning. We hypothesised that breathing helium-oxygen would reduce carbon dioxide production during the weaning phase of mechanical ventilation.

Materials/patients and methods

We performed a prospective randomised controlled single blinded cross-over trial on 19 adult intensive care patients without significant airways disease who fulfilled criteria for weaning with CPAP. Patients were randomised to helium-oxygen and air-oxygen delivered during a 2 hour period of CPAP ventilation. Carbon dioxide production (VCO₂) was measured using a near patient main stream infrared carbon dioxide sensor and fixed orifice pneumotachograph.

Results

Compared to air-oxygen, helium-oxygen significantly decreased VCO₂ production at the end of the 2 hour period of CPAP ventilation; there was a mean difference in CO₂ production of 48.9 ml/min (95% CI 18.7-79.2 p = 0.003) between the groups. There were no significant differences in other respiratory and haemodynamic parameters.

Conclusion

This study shows that breathing a helium-oxygen mixture during weaning reduces carbon dioxide production. This physiological study supports the need for a clinical trial of helium-oxygen mixture during the weaning phase of mechanical ventilation with duration of weaning as the primary outcome.

Trial registration

ISRCTN56470948     

Treatment of pregnant rats with oleoyl-estrone slows down pup fat deposition after weaning

Background  

In rats, oral oleoyl-estrone (OE) decreases food intake and body lipid content. The aim of this study was to determine whether OE treatment affects the energy metabolism of pregnant rats and eventually, of their pups; i.e. changes in normal growth patterns and the onset of obesity after weaning.     

Ocean climate and seal condition

Background  

The condition of many marine mammals varies with fluctuations in productivity and food supply in the ocean basin where they forage. Prey is impacted by physical environmental variables such as cyclic warming trends. The weaning weight of northern elephant seal pups, Mirounga angustirostris, being closely linked to maternal condition, indirectly reflects prey availability and foraging success of pregnant females in deep waters of the northeastern Pacific. The aim of this study was to examine the effect of ocean climate on foraging success in this deep-diving marine mammal over the course of three decades, using cohort weaning weight as the principal metric of successful resource accrual.     

Differences in Clinical Outcomes According to Weaning Classifications in Medical Intensive Care Units

Background

Although the weaning classification based on the difficulty and duration of the weaning process has been evaluated in the different type of intensive care units (ICUs), little is known about clinical outcomes and validity among the three groups in medical ICU. The objectives of this study were to evaluate the clinical relevance of weaning classification and its association with hospital mortality in a medical ICU with a protocol-based weaning program.

Methods

All consecutive patients admitted to the medical ICU and requiring mechanical ventilation (MV) for more than 24 hours were prospectively registered and screened for weaning readiness by a standardized weaning program between July 2010 and June 2013. Baseline characteristics and outcomes were compared across weaning classifications.

Results

During the study period, a total of 680 patients were weaned according to the standardized weaning protocol. Of these, 457 (67%) were classified as simple weaning, 136 (20%) as difficult weaning, and 87 (13%) as prolonged weaning. Ventilator-free days within 28 days decreased significantly from simple to difficult to prolonged weaning groups (P < 0.001, test for trends). In addition, reintubation within 48 hours after extubation (P < 0.001) and need for tracheostomy during the weaning process (P < 0.001) increased significantly across weaning groups. Finally, ICU (P < 0.001), post-ICU (P = 0.001), and hospital (P < 0.001) mortalities significantly increased across weaning groups. In a multiple logistic regression model, prolonged weaning but not difficult weaning was still independently associated with ICU (adjusted OR 8.265, 95% CI 3.484–19.605, P < 0.001), and post-ICU (adjusted OR 3.180, 95% CI 1.349–7.497, P = 0.005), and hospital (adjusted OR 5.528, 95% CI 2.801–10.910, P < 0.001) mortalities.

Conclusions

Weaning classification based on the difficulty and duration of the weaning process may provide prognostic information for mechanically ventilated patients who undergo the weaning process.     

The index herd with PMWS in Sweden: Presence of serum amyloid A,circovirus 2 viral load and antibody levels in healthy and PMWS-affected pigs

Background  

Postweaning Multisystemic Wasting Syndrome (PMWS) is an emerging disease in pigs of multifactorial origin, but associated to porcine circovirus type 2 (PCV2) infection. PMWS was first diagnosed in Sweden at a progeny test station that received pigs aged five weeks from 19 different nucleus herds on the day after weaning. The objective of this study was to examine, for the first time in an index outbreak of PMWS, the relationship between PCV2 virus, antibodies to PCV2 and serum amyloid a (SAA) in sequentially collected serum samples from pigs with and without signs of PMWS.     

Myocardial Injury after Surgery Is a Risk Factor for Weaning Failure from Mechanical Ventilation in Critical Patients Undergoing Major Abdominal Surgery

Background

Myocardial injury after noncardiac surgery (MINS) is a newly proposed concept that is common among adults undergoing noncardiac surgery and associated with substantial mortality. We analyzed whether MINS was a risk factor for weaning failure in critical patients who underwent major abdominal surgery.

Methods

This retrospective study was conducted in the Department of Critical Care Medicine of Peking University People''s Hospital. The subjects were all critically ill patients who underwent major abdominal surgery between January 2011 and December 2013. Clinical and laboratory parameters during the perioperative period were investigated. Backward stepwise regression analysis was performed to evaluate MINS relative to the rate of weaning failure. Age, hypertension, chronic renal disease, left ventricular ejection fraction before surgery, Acute Physiologic and Chronic Health Evaluation II score, pleural effusion, pneumonia, acute kidney injury, duration of mechanical ventilation before weaning and the level of albumin after surgery were treated as independent variables.

Results

This study included 381 patients, of whom 274 were successfully weaned. MINS was observed in 42.0% of the patients. The MINS incidence was significantly higher in patients who failed to be weaned compared to patients who were successfully weaned (56.1% versus 36.5%; P<0.001). Independent predictive factors of weaning failure were MINS, age, lower left ventricular ejection fraction before surgery and lower serum albumin level after surgery. The MINS odds ratio was 4.098 (95% confidence interval, 1.07 to 15.6; P = 0.04). The patients who were successfully weaned had shorter hospital stay lengths and a higher survival rate than those who failed to be weaned.

Conclusion

MINS is a risk factor for weaning failure from mechanical ventilation in critical patients who have undergone major abdominal surgery, independent of age, lower left ventricular ejection fraction before surgery and lower serum albumin levels after surgery.     

Hemoglobin Levels and Weaning Outcome of Mechanical Ventilation in Difficult-To-Wean Patients: A Retrospective Cohort Study

Introduction

The effect of hemoglobin levels on the weaning outcomes of mechanically ventilated patients remains under debate, particularly for the patients with difficult weaning. This study aims to evaluate the effect of hemoglobin levels on weaning outcomes in difficult-to-wean patients.

Methods

This retrospective cohort study was conducted in a university-affiliated teaching hospital in Taiwan. Patients who fulfilled the criteria of difficult weaning were enrolled. Medical records were reviewed to obtain data on hemograms, biochemistry tests, transfusion records, comorbidities and weaning outcome. The association between hemoglobin levels and 30-day weaning outcomes was evaluated using a logistic regression model.

Results

A total of 751 patients received mechanical ventilation during the study period, 138 of whom fulfilled the criteria of difficult weaning. Compared with the patients whose hemoglobin was <8 g/dL, those with higher hemoglobin levels were more likely to be successfully weaned (odds ratio [OR], 3.69; 95% CI, 1.22–11.15 for hemoglobin 8–10 g/dL and OR, 4.16, 95% CI, 1.30–13.29 for hemoglobin >10 g/dL). Multivariate analysis showed that the odds ratio for weaning success remained significant for hemoglobin levels of 8–10 g/dL (adjusted OR, 3.3; 95% CI, 1.07–10.15) with borderline significance for hemoglobin level > 10 g/dL (adjusted OR, 2.95, 95% CI, 0.88–9.96).

Conclusions

Hemoglobin level is independently associated with weaning outcome in difficult-to-wean patients. Further studies are needed to evaluate whether a restrictive transfusion trigger for acute critical illness is also appropriate for such patients.     

Early Weaning Stress in Pigs Impairs Innate Mucosal Immune Responses to Enterotoxigenic E. coli Challenge and Exacerbates Intestinal Injury and Clinical Disease

Background and Aims

The clinical onset and severity of intestinal disorders in humans and animals can be profoundly impacted by early life stress. Here we investigated the impact of early weaning stress in pigs on intestinal physiology, clinical disease, and immune response to subsequent challenge with enterotoxigenic F18 E. coli (ETEC).

Methodology

Pigs weaned from their dam at 16 d, 18 d, and 20 d of age were given a direct oral challenge of F18 ETEC at 26 d of age. Pigs were monitored from days 0 to 4 post-infection for clinical signs of disease. On Day 4 post-ETEC challenge, ileal barrier function, histopathologic and inflammatory cytokine analysis were performed on ileal mucosa.

Results

Early weaned pigs (16 d and 18 d weaning age) exhibited a more rapid onset and severity of diarrhea and reductions in weight gain in response to ETEC challenge compared with late weaned pigs (20 d weaning age). ETEC challenge induced intestinal barrier injury in early weaned pigs, indicated by reductions in ileal transepithelial electrical resistance (TER) and elevated FD4 flux rates, in early weaned pig ileum but not in late weaned pigs. ETEC-induced marked elevations in IL-6 and IL-8, neutrophil recruitment, and mast cell activation in late-weaned pigs; these responses were attenuated in early weaned pigs. TNF levels elevated in ETEC challenged ileal mucosa from early weaned pigs but not in other weaning age groups.

Conclusions

These data demonstrate the early weaning stress can profoundly alter subsequent immune and physiology responses and clinical outcomes to subsequent infectious pathogen challenge. Given the link between early life stress and gastrointestinal diseases of animals and humans, a more fundamental understanding of the mechanisms by which early life stress impacts subsequent pathophysiologic intestinal responses has implications for the prevention and management of important GI disorders in humans and animals.     

Effects of birth-rearing type on weaning weights in meat sheep are systematically associated with differences in mean performance among flocks

Background

Adjustment of body weights for systematic environmental effects such as dam age and litter size is essential for accurate prediction of breeding values in meat sheep and often accomplished by pre-adjusting records using simple multiplicative adjustment factors, which are derived as ratios of least-squares means of weights of lambs in target and reference classes. However, increasing use of multibreed genetic evaluations that incorporate data from both purebred and commercial flocks has generated concerns regarding the ability of simple additive or multiplicative adjustment factors to properly correct for environmental effects in flocks that differ widely in mean performance. Thus, consistency of adjustment factors across flocks and systematic effects of the level of flock performance on these factors were evaluated using data from the US National Sheep Improvement Program.

Methods

We used birth and weaning weights of lambs from 29 flocks that had at least 500 records per flock and represented several terminal-sire sheep breeds. Effects of lamb sex, dam age class and litter size on birth weights, and of dam age class and combined effects of type of birth and rearing on weaning weights were evaluated. Interactions between these effects and flock were assessed. Bias associated with different adjustment protocols was evaluated for high- and low-performance flocks.

Results

Effects of litter size and differences between yearling and adult dams varied (P < 0.001) among flocks. For weaning weights, additive adjustment factors were not associated with the level of flock performance, but multiplicative adjustment factors were strongly and inversely related to flock means for weaning weights (W). Flock-specific adjustment factors (F = αW^β) reduced bias in adjusted weaning weights associated with differences in flock performance. By contrast, simple multiplicative adjustment factors were appropriate to adjust birth weights.

Conclusions

Differences in weaning weights among single, twin, and triplet lambs were inversely related to the level of flock performance. Use of simple multiplicative adjustment factors led to adjustment bias when applied across flocks with large differences in mean performance. This bias was reduced by using additive adjustment factors or multiplicative factors that were derived as simple exponential functions of flock means for weaning weight.     

Genetic and environmental heterogeneity of residual variance of weight traits in Nellore beef cattle

Background

Many studies have provided evidence of the existence of genetic heterogeneity of environmental variance, suggesting that it could be exploited to improve robustness and uniformity of livestock by selection. However, little is known about the perspectives of such a selection strategy in beef cattle.

Methods

A two-step approach was applied to study the genetic heterogeneity of residual variance of weight gain from birth to weaning and long-yearling weight in a Nellore beef cattle population. First, an animal model was fitted to the data and second, the influence of additive and environmental effects on the residual variance of these traits was investigated with different models, in which the log squared estimated residuals for each phenotypic record were analyzed using the restricted maximum likelihood method. Monte Carlo simulation was performed to assess the reliability of variance component estimates from the second step and the accuracy of estimated breeding values for residual variation.

Results

The results suggest that both genetic and environmental factors have an effect on the residual variance of weight gain from birth to weaning and long-yearling in Nellore beef cattle and that uniformity of these traits could be improved by selecting for lower residual variance, when considering a large amount of information to predict genetic merit for this criterion. Simulations suggested that using the two-step approach would lead to biased estimates of variance components, such that more adequate methods are needed to study the genetic heterogeneity of residual variance in beef cattle.     

Clinical Verification of A Clinical Decision Support System for Ventilator Weaning

Background

Weaning is typically regarded as a process of discontinuing mechanical ventilation in the daily practice of an intensive care unit (ICU). Among the ICU patients, 39%-40% need mechanical ventilator for sustaining their lives. The predictive rate of successful weaning achieved only 35-60% for decisions made by physicians. Clinical decision support systems (CDSSs) are promising in enhancing diagnostic performance and improve healthcare quality in clinical setting. To our knowledge, a prospective study has never been conducted to verify the effectiveness of the CDSS in ventilator weaning before. In this study, the CDSS capable of predicting weaning outcome and reducing duration of ventilator support for patients has been verified.

Methods

A total of 380 patients admitted to the respiratory care center of the hospital were randomly assigned to either control or study group. In the control group, patients were weaned with traditional weaning method, while in the study group, patients were weaned with CDSS monitored by physicians. After excluding the patients who transferred to other hospitals, refused further treatments, or expired the admission period, data of 168 and 144 patients in the study and control groups, respectively, were used for analysis.

Results

The results show that a sensitivity of 87.7% has been achieved, which is significantly higher (p<0.01) than the weaning determined by physicians (sensitivity: 61.4%). Furthermore, the days using mechanical ventilator for the study group (38.41 ± 3.35) is significantly (p<0.001) shorter than the control group (43.69 ± 14.89), with a decrease of 5.2 days in average, resulting in a saving of healthcare cost of NT$45,000 (US$1,500) per patient in the current Taiwanese National Health Insurance setting.

Conclusions

The CDSS is demonstrated to be effective in identifying the earliest time of ventilator weaning for patients to resume and sustain spontaneous breathing, thereby avoiding unnecessary prolonged ventilator use and decreasing healthcare cost.

     

Effect of Tracheostomy on Weaning Parameters in Difficult-to-Wean Mechanically Ventilated Patients: A Prospective Observational Study

Background and Objective

Weaning parameters are commonly measured through an endotracheal tube in mechanically ventilated patients recovering from acute respiratory failure, however this practice has rarely been evaluated in tracheostomized patients. This study aimed to investigate changes in weaning parameters measured before and after tracheostomy, and to explore whether the data measured after tracheostomy were associated with weaning outcomes in difficult-to-wean patients.

Methods

In a two-year study period, we enrolled orotracheally intubated patients who were prepared for tracheostomy due to difficult weaning. Weaning parameters were measured before and after the conversion to tracheostomy and compared, and the post-tracheostomy data were tested for associations with weaning outcomes.

Results

A total of 86 patients were included. After tracheostomy, maximum inspiratory pressure (mean difference (Δ) = 4.4, 95% CI, 2.7 to 6.1, P<0.001), maximum expiratory pressure (Δ = 5.4, 95% CI, 2.9 to 8.0, P<0.001) and tidal volume (Δ = 33.7, 95% CI, 9.0 to 58.5, P<0.008) significantly increased, and rapid shallow breathing index (Δ = -14.6, 95% CI, -25.4 to -3.7, P<0.009) and airway resistance (Δ = -4.9, 95% CI, -5.8 to -4.0, P<0.001) significantly decreased. The patients who were successfully weaned within 90 days of the initiation of mechanical ventilation had greater increments in maximum inspiratory pressure (5.9 vs. 2.4, P = 0.04) and maximum expiratory pressure (8.0 vs. 2.0, P = 0.02) after tracheostomy than those who were unsuccessfully weaned.

Conclusions

In conclusion, the conversion from endotracheal tube to tracheostomy significantly improved the measured values of weaning parameters in difficult-to-wean patients who subsequently weaned successfully from the mechanical ventilator. The change was significant only for airway resistance in patients who failed weaning.

Trial Registration

ClinicalTrials.gov NCT01312142     

Effects of early contact between non-littermate piglets and of the complexity of farrowing conditions on social behaviour and weight gain

In this study we tested if contact possibilities between non-littermate piglets and complexity of farrowing conditions affect the pre- and post-weaning behaviour, weight gain and skin lesions of piglets. Suckling sows were either kept in a group housing system (GH), in a single pen loose housing system (LH), or in conventional farrowing crates (FC). In the single pen systems a piglet door to the adjacent pen was opened on d 10 after farrowing in half of the pens so that piglets were able to enter the neighbouring pen (LH+ and FC+). For control, in the other half of single pens no piglet doors were opened (LH− and FC−). In the group housing system piglets also were allowed to freely move within the whole system on d 10 after farrowing. After weaning on d 28 piglets were kept in littered rearing pens in an open stable holding 20 piglets each. Piglets from contact pens were mixed with those they previously had contact to whereas piglets from control pens were mixed with unfamiliar litters. Data were obtained from 230 litters (113 sows with 1935 farrowed piglets). All piglets were scored for skin lesions immediately before and 4 days after opening the piglet doors, as well as immediately before and 4 days after moving into rearing pens. Behaviour (biting, fighting, drinking and laying) of piglets was recorded in the rearing pens in a 48-h period after weaning for 2 × 4 h. Treatments did not affect the level of skin lesions in the rearing period (H = 8.72, df 4, ns) nor daily weight gain until weaning (F_4,216 = 1.21, ns). In the 48 h after moving to rearing pens, less intensive agonistic behaviour (fighting and biting) was observed in contact piglets (H = 53.36, df 4, P < 0.0001). Four days after weaning control piglets showed significantly higher numbers and more severe skin lesions than contact piglets and, in addition, lesion scores of piglets from the larger single farrowing pens with straw bedding were significantly lower compared to the single farrowing crate (H = 33.86, df 4, P < 0.0001). The latency for lying in the new rearing pen was decreasing (F_4,93 = 25.76, P < 0.001) and the latency for drinking (F_4,81 = 3.43, P = 0.01) was increasing with decreasing complexity and space allotment of the housing system but were not related to whether the piglets have had contact to other litters before weaning. Five weeks after weaning weight gain (F_4,204 = 7.01, P < 0.0001) and BW (F_4,207 = 5.34, P < 0.001) were higher in treatments offering contact. Our results show that familiarising piglets from different litters 10 day post partum by establishing contact possibilities through a piglet door reduces social stress at weaning and increases weight gain after weaning. Farrowing pens with straw bedding and enlarged space as offered in the farrowing pens and the group housing system can further decrease the level of harmful agonistic interactions after mixing unacquainted litters at weaning and can improve the adaptation of piglets towards the new environment of the rearing pen.     

Does bromocriptine play a role in decreasing oxidative stress for early weaned programmed obesity?

Aims

Studies have demonstrated that early weaning can promote metabolic syndrome during adulthood and that obesity increases oxidative stress. Thus, we aimed to evaluate redox status in a pharmacological early weaning rodent model programmed for metabolic syndrome at adulthood.

Main methods

Lactating dams were randomly assigned into 2 groups: the early weaning group (BRO), which was treated intraperitoneally with bromocriptine (1 mg/day) to inhibit prolactin secretion for the last 3 days of lactation, and the control group (C), which received the BRO diluent for the same time period. The offspring were killed at 90 (PN90) and 180 (PN180) days after birth.

Key findings

Early weaning induced greater visceral adiposity and dyslipidemia. At PN90, the BRO offspring showed glucose intolerance with normoinsulinemia and increased plasma and liver superoxide dismutase, and liver glutathione peroxidase activities, which reduced the liver malondialdehyde but not the increased plasma malondialdehyde levels. However, the BRO offspring showed insulin resistance at PN180 and increased plasma glutathione peroxidase, liver superoxide dismutase, and catalase activities. These changes reduced the plasma and liver malondialdehyde levels, which aided in hepatocyte architecture preservation. Additionally, we observed that sirtuin 1 was overexpressed in the BRO group at PN90, but the increased expression was not maintained through PN180, which suggests unfavorable metabolic conditions in the older offspring.

Significance

Despite the observed obesity and glucose homeostasis dysfunction, our data suggest that the early weaning programming induced by bromocriptine can improve the offspring's redox status and may prevent liver damage during adulthood.     

Differential Effects of Early Weaning for HIV-Free Survival of Children Born to HIV-Infected Mothers by Severity of Maternal Disease

Background

We previously reported no benefit of early weaning for HIV-free survival of children born to HIV-infected mothers in intent-to-treat analyses. Since early weaning was poorly accepted, we conducted a secondary analysis to investigate whether beneficial effects may have been hidden.

Methods

958 HIV-infected women in Lusaka, Zambia, were randomized to abrupt weaning at 4 months (intervention) or to continued breastfeeding (control). Children were followed to 24 months with regular HIV PCR tests and examinations to determine HIV infection or death. Detailed behavioral data were collected on when all breastfeeding ended. Most participants were recruited before antiretroviral treatment (ART) became available. We compared outcomes among mother-child pairs who weaned earlier or later than intended by study design adjusting for potential confounders.

Results

Of infants alive, uninfected and still breastfeeding at 4 months in the intervention group, 16.1% who weaned as instructed acquired HIV or died by 24 months compared to 16.0% who did not comply (p = 0.98). Children of women with less severe disease during pregnancy (not eligible for ART) had worse outcomes if their mothers weaned as instructed (RH = 2.60 95% CI: 1.06–6.36) compared to those who continued breastfeeding. Conversely, children of mothers with more severe disease (eligible for ART but did not receive it) who weaned early had better outcomes (p-value interaction = 0.002). In the control group, weaning before 15 months was associated with 3.94-fold (95% CI: 1.65–9.39) increase in HIV infection or death among infants of mothers with less severe disease.

Conclusion

Incomplete adherence did not mask a benefit of early weaning. On the contrary, for women with less severe disease, early weaning was harmful and continued breastfeeding resulted in better outcomes. For women with more advanced disease, ART should be given during pregnancy for maternal health and to reduce transmission, including through breastfeeding.

Trial Registration

Clinical trials.gov {"type":"clinical-trial","attrs":{"text":"NCT00310726","term_id":"NCT00310726"}}NCT00310726     

Prediction of Post-Weaning Fibrinogen Status during Cardiopulmonary Bypass: An Observational Study in 110 Patients

Background

After cardiac surgery with cardiopulmonary bypass (CPB), acquired coagulopathy often leads to post-CPB bleeding. Though multifactorial in origin, this coagulopathy is often aggravated by deficient fibrinogen levels.

Objective

To assess whether laboratory and thrombelastometric testing on CPB can predict plasma fibrinogen immediately after CPB weaning.

Patients / Methods

This prospective study in 110 patients undergoing major cardiovascular surgery at risk of post-CPB bleeding compares fibrinogen level (Clauss method) and function (fibrin-specific thrombelastometry) in order to study the predictability of their course early after termination of CPB. Linear regression analysis and receiver operating characteristics were used to determine correlations and predictive accuracy.

Results

Quantitative estimation of post-CPB Clauss fibrinogen from on-CPB fibrinogen was feasible with small bias (+0.19 g/l), but with poor precision and a percentage of error >30%. A clinically useful alternative approach was developed by using on-CPB A10 to predict a Clauss fibrinogen range of interest instead of a discrete level. An on-CPB A10 ≤10 mm identified patients with a post-CPB Clauss fibrinogen of ≤1.5 g/l with a sensitivity of 0.99 and a positive predictive value of 0.60; it also identified those without a post-CPB Clauss fibrinogen <2.0 g/l with a specificity of 0.83.

Conclusions

When measured on CPB prior to weaning, a FIBTEM A10 ≤10 mm is an early alert for post-CPB fibrinogen levels below or within the substitution range (1.5–2.0 g/l) recommended in case of post-CPB coagulopathic bleeding. This helps to minimize the delay to data-based hemostatic management after weaning from CPB.     

Initial breastfeeding attitudes and practices of women born in Turkey, Vietnam and Australia after giving birth in Australia

Background

Many studies of the impact of breastfeeding on child or maternal health have relied on data reported retrospectively. The goal of this study was to assess recall accuracy among breastfeeding mothers of retrospectively collected data on age of weaning, reasons for cessation, breast pain, lactation mastitis, and pumping.

Methods

Women in Michigan and Nebraska, U.S.A. were interviewed by telephone every 3 weeks during the first 3 months after the birth of their child, and mailed a questionnaire at 6 months. A subset was interviewed again by telephone approximately 1–3.5 years after the birth. The results for the three recall periods, collected 1994–1998, were compared using correlation, linear and Cox regression analysis, and sensitivity and specificity estimates.

Results

The 184 participants were aged 18–42, mostly white (95%) and 63% had an older child. The age of weaning tended to be overestimated in interviews 1–3.5 years after birth compared to those within 3 weeks of the event, by approximately one month for 1–3.5 year recall and two weeks for 6-month recall (p < 0.001 in both cases). Recall accuracy of reasons for weaning varied greatly by reason, with mastitis and return to work having the most recall validity. The sensitivity of 1–3.5 year recall of mastitis was 80%, but was only 54% for nipple cracks or sores.

Conclusion

Breastfeeding duration among short-term breastfeeders tended to be somewhat overestimated when measured at 1–3.5 years post-partum. Reporting of other breastfeeding characteristics had variable reliability. Studies employing retrospective breastfeeding data should consider the possibility of such errors.